About this page. This page summarises a Domestic Homicide Review published in the Home Office DHR Library. The full report is available at the source link below. Victim and perpetrator names are not included in extracted summaries on this page.
Source · Domestic Homicide Review
Cornwall review
CSP: Cornwall
Published: September 2023
Year of death: 2012
Extracted: 37 recs
Statutory domestic homicide review under section 9 of the Domestic Violence, Crime and Victims Act 2004. Source: Home Office DHR Library.
View full report (PDF) ↗
Source: Home Office DHR Library
Summary
The review identified significant deficits in mental health care, including inadequate risk assessment focused solely on the perpetrator's self-harm risk, poor record-keeping, and lack of continuity of care. There was a failure to recognise domestic abuse indicators, offer a carer's assessment to the victim, or consider the perpetrator's delusional jealousy as a risk to others.
Extracted recommendations
| # | Recommendation | Addressed to |
|---|---|---|
| 1 | We recommend that there should be a clear and robust domestic abuse policy in place at each GP surgery in the county. These policies should be regularly reviewed by practice managers and subject to audit at regular intervals. Such a policy should be distinct and separate from policies relating to Safeguarding. | NHS Kernow | Kernow CIC |
| 1 | Consideration should be given to reviewing the mechanisms for triggering a response under the Neighbourhood Harm Reduction Register, particularly where cases straddle two consecutive periods. Refinements to this process may improve opportunities to coordinate a holistic response to individuals coming to police attention as a result of mental health issues. | Devon & Cornwall Police |
| 1 | Undertake a formal regular audit of complex cases, which includes the impact on other family members | NHS England |
| 1 | CFT review the current performance data for dates / timescales of review, undertake an audit of records to consider overall standards of record keeping and quality of content. Develop an action plan as required. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 10 | We recommend a programme of work to review recording processes and an associated regular audit of recording practice. In particular this should focus on the requirements to ensure written care plans are in place, that risk assessments are properly recorded and appropriately reviewed and updated. In addition, focus should be given to ensuring that staff working in local organisations fully understand how to utilise the electronic recording systems that are currently used in statutory organisations. In addition, the matters relating to missing or incorrectly coded medical records should be subject to review by CFT to establish the reasons for the lack of historical notes and measures put in place to ensure CFT request copies of all historic mental health care notes from the GP to be uploaded into the current clinical record. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 10 | Staff in HTT and CMHT are prioritised to undertake the Domestic Abuse and DASH (Domestic Abuse, Stalking, Harassment and Honour Based Violence) two day training | NHS Kernow | Cornwall Foundation Partnership Trust |
| 11 | We recommend that a focused themed review of previous DHRs in Cornwall be undertaken to identify common themes and issues, from which focused learning and practice development can take place with local organisations. We make this recommendation in the context of there having been previous DHRs in Cornwall where the quality of risk assessment in the wider context of an individual and the effect this may have on understanding whether they pose a risk to others is an area of practice that should be considered for wider learning and practice development. There is one particular case that the panel is aware of from discussions with the family of the victim and although it is outside the scope of this DHR to review that case we believe there may be commonalities and it would be of benefit to the local system to know and understand these so that a co-ordinated approach to learning and development can be undertaken in response to DHRs undertaken as a whole rather than seeing each in isolation. | DASV & SOC Strategy Lead |
| 11 | CFT to consider how carers assessments might be used to consider concerns about domestic abuse. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 12 | Clinical staff to ensure there is opportunity and time to interview both service user and partner separately to be able to take account of domestic abuse, allowing time for disclosure. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 13 | Clinical staff to ensure the service user is asked when they are on their own if they wish their partner to be present in clinical meetings, and staff to document this. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 14 | Review of job descriptions to ensure staff are clear their adult and child safeguarding responsibilities include responding to concerns about domestic abuse. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 15 | Employers responsibilities to victims of domestic abuse to be referenced in CFT disciplinary policy | NHS Kernow | Cornwall Foundation Partnership Trust |
| 16 | The Trust consider working arrangements between NHS and private practice. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 2 | We recommend that a training needs analysis for GP’s, mental health workers and others should be conducted to identify which staff would benefit from training in recognising markers for domestic abuse. Further work should be undertaken across local agencies to ensure the dissemination of regular training and information in relation to domestic abuse. In particular the use of a specialist package like IRIS to support GPs in their responses to domestic abuse should be used. Work should also be undertaken in relation to training in recognising signs of and risks of coercion and control, which has recently been legislated for. All training should highlight the fact that domestic abuse may be perpetrated by women on men as well as vice versa. | NHS Kernow | Kernow CIC |
| 2 | It is recommended that D140 (Mental Health Issues Policy) be reviewed with a view to drawing together risk areas, including domestic abuse, mental health, missing persons and child abuse investigation. Guidance and procedures should be reviewed with consideration to incorporating a ‘think family’ approach under mental health protocols and practices. | Devon & Cornwall Police |
| 2 | NHS England action the training needs of GPs as identified within their current audit. | NHS England |
| 2 | CFT use the 'Human error model' to identify the cause of poor practice in record keeping in clinical records (slip/lapse, mistake, violation) and design a solution based on the findings. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 3 | We recommend that direct enquiry into domestic abuse is used by all agencies in any assessment or risk assessment process. Direct enquiry should be considered as part of the tool kit of skills and interventions to be utilised within statutory organisations. | Safer Cornwall Strategic Board |
| 3 | GPs develop a consistent approach to regular risk assessments that are formally shared with other relevant agencies and a copy is stored within the notes. | NHS England |
| 3 | CFT provide an easy to read aid memoire card to clinical staff outlining good practice and expected structure of writing progress notes. The aim is to improve the quality of the progress notes, for staff to consistently record information in a structured format that includes: date, time of contact, purpose of contact, assessment of presentation of service user, risk assessment, rationale for decisions, link to care plan and plan of action. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 4 | We recommend that assessment and risk assessment processes be reviewed to ensure clearer guidance about the need to consider and respond not only to the risks of harm to the individual, but also to others including spouses, partners and children. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 4 | Further identification of areas within current practice where processes need to be developed or tightened to ensure cohesive support for individuals and their immediate family. | NHS England |
| 4 | Review of current RiO quality manual and risk management policy to ensure the information is clear and compatible. Establish clear standards for how to use the risk summary, including staff must record in each section, where there is no new information staff to record ‘no new information’. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 5 | We recommend that a programme of work be undertaken in relation to the provision of carer’s assessments. There is a statutory requirement to offer a carer’s assessment. Work is required to ensure that this duty is being met and it should be regularly audited. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 5 | Joint training (in relation to domestic abuse and safeguarding) is undertaken as standard, wherever possible. | NHS England |
| 5 | When the RiO system is redesigned by CFT in 2015: . A comprehensive admission clerking in process be required by junior doctors, that it is recorded in one place and that it is audited. . Clinical staff from a range of services to be involved in order the system is designed to meet clinical need and improve the teams understanding of how the system works and should be used. . Develop specific guidance for RiO to identify the expected standards of use for each function in RiO. . CFT to audit the expected standards for RiO functions. CFT to provide exception reporting to individual staff, and teams to ensure learning and improve consistency of how staff use RiO. . Ensure the core risk areas include a drop down box list of known associations with high risk. Include in this list - relationship difficulties, domestic abuse and pathological jealousy. . CFT to review the RiO guidance to ensure it clearly states staff are required to record narrative in the ‘reasons box’, source of information and rationale for decision Policy Development. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 6 | We recommend that training be put in place to develop the skills and expertise of health care professionals in working with physician patients or those who may have health care expertise and experience | NHS Kernow | Cornwall Foundation Partnership Trust |
| 6 | Consideration of the thresholds for referrals/communication between agencies and where unnecessary waiting, gaps or insufficient communication will cause significant risks to individuals. | NHS England |
| 6 | The supervision policy to be reviewed to ensure case load supervision includes the expectation for line managers to view random samples of records, look at content and quality. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 7 | We recommend work be undertaken to develop further skills in risk assessment and risk management to ensure that methods and approaches are consistent with current standards in specific organisations and that in particular, professionals routinely consider the potential for risk to others, whether or not this is articulated by the individual being worked with. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 7 | That the learning from these domestic homicide reviews is routinely shared with professionals working within adult and children’s services to facilitate proactive support that could minimise the potential for escalating risk or reoccurrence within the next generation. | NHS England |
| 7 | CFT to introduce a policy requiring staff to document information about care and staff involvement at the time of an incident which is reported as a Serious Incident (SI). | NHS Kernow | Cornwall Foundation Partnership Trust |
| 8 | We recommend that a process and protocol be put in place to guide practitioners and managers about how best to ensure continuity of care provisions, most notably, continuity of worker. Recognising the constraints of workforce capacity and workload, it is nevertheless important to place emphasis on the need to provide continuity wherever possible. Such a protocol should include guidance about decision making relating to the appropriate use of qualified and non-qualified staff. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 8 | That the full impact on understanding the potential risks and management of individuals with complex mental health needs are addressed through the support systems and time offered to both professionals and carers. | NHS England |
| 8 | CFT provide training to clinical staff about pathological jealousy | NHS Kernow | Cornwall Foundation Partnership Trust |
| 9 | We recommend that a process and protocol be put in place across Cornwall to ensure the timely and appropriate notification of GP’s about care plans, current treatment and changes to that, including hospital discharge by secondary care NHS Trust providers. | NHS Kernow | Cornwall Foundation Partnership Trust |
| 9 | STORM trainer to advise staff the use of "guaranteeing safety‟ is not mental health terminology, is not an assessment of risk, this is poor practice and should not be used in documentation. Training to remind staff their assessment requires documentation of the discussion about risk, protective factors, risk rating and the management plan. | NHS Kernow | Cornwall Foundation Partnership Trust |
| Recommendations extracted from the published report. Source: Home Office DHR Library. View full report ↗ | ||